Provider Demographics
NPI:1790416204
Name:O'GORMAN, LIA (LCSW)
Entity Type:Individual
Prefix:
First Name:LIA
Middle Name:
Last Name:O'GORMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W SENECA ST STE 205
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-2480
Mailing Address - Country:US
Mailing Address - Phone:585-653-0229
Mailing Address - Fax:
Practice Address - Street 1:7100 RAWSON RD
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NY
Practice Address - Zip Code:14727-9281
Practice Address - Country:US
Practice Address - Phone:585-610-6762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0922201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical